Adverse Childhood Experiences and Health Disparities: Why Collective Action Is Needed

“Law serves human values.”

Hon. Peter Rubin, ACS founder and (since 2008) justice of the Massachusetts Appeals Court, in an address to the Columbia Law School ACS Student Chapter, January 19, 2006.

**NOTE: This post first appeared on the ACSblog on July 7, 2015. I am cross-posting it here.**

From its founding, ACS has advocated for true equality of opportunity, the taproot of American democracy. Rejecting the formal equality yielded by more conservative readings of our Constitution and laws, instead we seek equity—an authentically fair chance for all.

But equity evades easy solutions, and inequity is spread so broadly across so many dimensions it’s difficult to know where to start. The answer, as I’ve written previously in this space, may well lie in approaches informed by collective impact—a modern Archimedes’ lever. Consider the work of Nadine Burke Harris, M.D., MPH, FAAP, a pediatrician who started a clinic in the Bayview neighborhood of San Francisco following her residency at Stanford. On Thursday, July 2, Dr. Burke Harris visited Orrick, Herrington & Sutcliffe to address an audience filled with United Way of the Bay Area Women’s Leadership Council members, ACS Bay Area Lawyer Chapter members, and their guests.

The Bayview is a neighborhood rich in family and community ties. But it is poor in resources and health, and suffers one of the the highest crime rates in the city. After Dr. Burke Harris opened the Bayview Child Health Center, she began to see the links links between early childhood adversity and health. She began to see children coming to the clinic with high rates of asthma, ADHD, and other childhood illnesses at many times the rate of the general population. “Doctora,” one of her patients explained, “it seems like my daughter’s asthma is worse when her daddy punches a hole in the wall.” That’s obviously terrifying for a child—but why would asthma follow?

As Dr. Burke Harris recounts, the answer materialized when a colleague came to her with the 1998 Kaiser study called “Adverse Childhood Experiences,” or ACEs. This  was the “aha” moment that would ultimately change the course of her career and lead to creation of the Center for Youth Wellness.

ACEs are stressful and potentially traumatic experiences over which a child has no control. These experiences can have lifelong implications for health and future succcess.

In 1998, a Centers for Disease Control (CDC) study conducted with Kaiser Permanente studied the childhood experiences of 17,000 KP patients (science nerds can find the peer-reviewed study here). Its purpose was to understand connections between childhood adversity and later health outcomes. It tested for seven specific events: psychological, physical, or sexual abuse; violence against the mother; living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The study, since replicated, yielded stunning results. ACEs are remarkably prevalent, they are universal, and persons with four or more face substantial lifetime risk of serious health problems and early mortality.

Exposure to ACEs and toxic stress can compound across communities and generations.

Dr. Burke Harris has found that “the principal actor in the link between ACEs and disease is . . . the body’s ‘fight-or-flight’ response.” That heart-pounding response that is evolutionarily useful when you have to fight a bear becomes toxic when activated over and over and over in the presence of violence or other trauma. ACE researchers now know that toxic stress alters gene expression. And they suspect that these changes may be heritable, meaning that the impact of stressful environments may compound and become more complex from generation to generation. For example, some researchers now believe that ADHD ― attention deficit hyperactivity disorder ― can be a function of stress and/or poverty. And ADHD, which affects one in nine American children, is a brain condition that researchers believe is heritable.

Resilience and recovery from ACEs can be taught.

Dr. Burke Harris emphasizes that the ACEs cycle can absolutely be broken. Six powerful resilience factors can be taught to any affected person: sleep; diet; exercise; mental health care; meditation; and nurturing personal relationships. Once children at risk of ACE exposure are identified through screening, the Center for Youth Wellness staff can work with the child and family to protect and strengthen. Read more about current research into toxic stress biomarkers and co-occurring ACEs here.

Exposure to ACEs is a social justice and human rights issue.

We know that the ACEs cycle can be broken. But consider for a moment the list of factors in building resilience. For parents in vulnerable, low-income communities, obtaining fresh, healthy food can be a real challenge, as I’ve noted here. Sleep can be difficult when parental work schedules are chaotic, as often happens in the service jobs prevalent in the Bayview. Exercise opportunities can be limited by the lack of facilities and by public safety issues. Health disparities are, after all, socioeconomic disparities.

That’s where collective impact comes in. When several agencies and programs partner with the community and each other, durable gains are within reach. Dr. Burke Harris and her staff at the Center for Youth Wellness are working to improve the health outcomes for children and youth exposed to ACEs and toxic stress. But to do that, she needs a host of other partners to pull their own oars—community champions like Villy Wang of BAYCAT, a media arts business that trains and employs Bayview youth; Hunters Point Family, providing after-school learning and fitness for local kids; and City of Dreams, which mentors children living in low-income and public housing communities. The key is a joint focus on making the elements of resilience accessible to all—and, ultimately, on creating laws and policies that support and enhance the community’s capacity to provide them.

The road to true equity of opportunity is long, and we aren’t nearly there yet. But Dr. Burke Harris and her partners have started drawing the map in the Bayview and are beginning to have an impact nationally. Stay tuned.